Atilla Soran, MD, MPH, FACSProfessor of Surgery

Meme Kanserinde Risk Azaltıcı Cerrahiler: Profilaktik Cerrahi

Modifiye edilebilir Risk factorleri

• Behavioral factors

BMIAlcohol useSmokingExercise

• Dietary factors

Total fat intakeSaturated fat intake

• Ionizing radiation

• Hormone replacement

• Age

• Reproductive History

• Familial/genetic factors 

• Breast density

• Atypical/LCIS

• History of BC

• Ethnicity/Race

Modifiye edilemez faktorler

BPMBSO

Bilateral profilaksi

Koruyucu ilac tedavisi

Yakin takip

What do we know;

• Risk Reduction mastectomy – Reduces CBC incidence– Treats occult synchronous cancer– Prevents metachronous cancerBUT– irreversible/substantial– Complications– Unnecessary; absolute risk of CBC is low

» Survival benefit?• Alternatives

– Screening– Oophorectomy– Chemoprevention 

Risk Azaltıcı Cerrahiler

Bilateral Profilaktik Mastektomi

%6.8>20 yıl

%3 absult kazanç, %2.8 okult Ca

Risk azaltıcı Cerrahiler:Prophylactic oophorectomy

Prophylactic oophorectomy in BRCA1mutation carriers: effect on breast cancer incidence

Rebbeck TR, et al. JNCI 1999; 91:1475-1479

Estimates of the Time to Breast Cancer or BRCA‐Related Gynecologic Cancer after Salpingo‐Oophorectomy or Surveillance 

for Ovarian Cancer

Kauff ND, et al. N Engl J Med 2002; 346:1609-1615

(p = 0.006 by log-rank test)

CPM

RANDOMIZED TRIALS SHOW 

SURVIVAL  MASTECTOMY  =    SURVIVAL BCT

Newman et al. J Clin Onc. March 2005

SURVIVALBreast Cancer Surgery Journey

1894

Halsted-RM

1967 Fisher MRM

1981- Fischer BCS

2000- BM

MWH data05 06 07 08 09

BCS 606 629  683  706  618

All Mastectomy 272(31%) 

321(35%) 

377(35%) 

435 (38%) 

409(40%)

Mast+CPM+Reconstruc.

55(20%) 22(40%)

67(21%) 30(45%)

115(31%) 48(42%)

111(26%) 77(69%)

105 (26%)72(69%)

Total 878 905 1060 1141 1027

(2009) All Uni. Mastectomy + reconst: 25%

MWH

01020304050607080

Year 2005-2009

%of

pts TM

TM+CPMTM+CPM+RECONST

TM 31 35 35 38 40

TM+CPM 20 21 31 26 26

TM+CPM+RECONST

40 45 42 69 69

1 2 3 4 5

Tahmin edilebilir yıllık riskler (%)

•Yaş<30 .4‐1.3•Yaş>50 .2‐.4•HR negatif .2‐.6•HR (+) .1‐.4•2.‐3. derece akraba  minimal•1.derece akraba .2‐.8•Çoklu akraba 1.‐2. .4‐1.3•BRCA mutasyon .9‐3

•Ingrid et al.JACS. 2013

CBC 

DFS

Do patients with unilateral breast cancer benefit from more aggressive surgery ?

%4.3 BC survi de artma

CPM‐MRIMRI  at diagnosis increased from 1.3%  to  36.3% (1997‐2005) 

Date of download: 5/23/2014 Copyright © 2014 American Medical Association. All rights reserved.

From: Social and Clinical Determinants of Contralateral Prophylactic Mastectomy

JAMA Surg. 2014;():. doi:10.1001/jamasurg.2013.5689

Study Flow DiagramSEER indicates Surveillance, Epidemiology, and End Results.

Date of download: 5/23/2014 Copyright © 2014 American Medical Association. All rights reserved.

From: Social and Clinical Determinants of Contralateral Prophylactic MastectomyJAMA Surg. 2014;():. doi:10.1001/jamasurg.2013.5689

Predicted Probabilities of Receipt of Treatments by Clinical Indications and Worry About RecurrenceAdjusted for age, race/ethnicity, education, income, stage, and study site.

Potential contributing factors

• Fear a 2nd BC• Changing perception

BCS /RT• Fear of CT/RT/HT• Martial status• Difficult/long surveillance • Experience of Chemoprevention • Socioeconomic status• Body image

• Media reports• Public awareness

•Age•Family history of BC•BRCA1/2 genetic testing•Invasive lobular histology•DCIS•Hormone replacement therapy

•Preoperative MRI w/ additional biopsy•Diagnostic difficulties for CBC•Failed attempt at BCT•Improved mastectomy •Reconstruction

Kathy Bates: The actress, who beat ovarian cancer close to a decade ago, shared last month that she had been diagnosed with breast cancer and underwent a double mastectomy.

Allyn Rose, Miss America Contestant, To Undergo Double Mastectomy To Prevent Breast Cancer

Double Mastectomy: Sharon Osbourne Undergoes Breast-Removal Surgery

CHRISTINA APPLEGATE: WHY SHE HAD A DOUBLE MASTECTOMY

Michelle Heaton speaks about her double mastectomy and says: “It’s the hardest thing in the world not being able to hold your child

"My chances of developing breast cancer have dropped from 87 percent to under 5 percent," Jolie wrote in a surprise op-ed published in …that applauded partner Brad Pitt's support. "I can tell my children that they don’t need to fear they will lose me to breast cancer."

Conclusion• Overall survival

– Selected pts most likely to benefit

• Risk reduction – Disease free survival

• Satisfaction w/cosmetic outcome• RR w Chemoprevention works in some pts and has side effects,

• Long term follow up is not always acceptable• It must be pt’s decision: CPM vs. alternative risk reduction procedures